Provider Demographics
NPI:1477878429
Name:KEDARISETTI, CHAITANYA DEEPTHI (PT)
Entity Type:Individual
Prefix:
First Name:CHAITANYA
Middle Name:DEEPTHI
Last Name:KEDARISETTI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 S LOVINGTON DR
Mailing Address - Street 2:APT 107
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-4370
Mailing Address - Country:US
Mailing Address - Phone:419-819-7314
Mailing Address - Fax:
Practice Address - Street 1:5428 METROPOLITAN PKWY
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-4103
Practice Address - Country:US
Practice Address - Phone:586-977-0001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-02
Last Update Date:2010-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014995225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist